HCWs suffer stress long after bloodborne exposures
Needlesticks make up majority of exposures
Health care workers who may have been exposed to bloodborne pathogens may experience high levels of stress up to a year after the exposure incident, even when they did not become infected with HIV or hepatitis C, researchers say.
In a study conducted at the Johns Hopkins School of Public Health in Baltimore and the Department of Infection Control at Holy Cross Hospital in Silver Spring, MD, investigators used a five-page, confidential, self-administered questionnaire to evaluate the circumstances surrounding possible exposures and the reactions of the exposed health care workers, according to lead author Robyn Gershon, MHS, DrPH, a scientist at the Johns Hopkins School of Hygiene and Public Health. Out of the 186 employees who experienced a possible exposure, 65 returned completed surveys. (The study is currently under consideration for publication by a peer-reviewed medical journal.)
Needlesticks are the most frequent cause
Fifty-six percent of those surveyed reported that their exposures came from needlesticks. Cuts accounted for 22%, splashes to eyes or mouth 21%, and exposures to open wounds were listed as the cause in 10% of incidents. Nearly 40% of respondents reported at least one other previous exposure. Many exposures occurred in the operating room, and many were caused by actions of co-workers, such as the improper disposal of sharps or needles. The researchers noted three exposure incidents that resulted after health care workers disposed of contaminated needles in an overfilled sharps container. One respondent was stuck after trying to dispose of three liver biopsy needles at once.
"Other unsafe acts also related to disposal were not infrequent and often dramatic," the study authors wrote. For instance, while attempting to remove a dirty knife blade improperly, an OR technician accidentally launched the blade into the arm of another nurse. The nurse who was cut wrote that "the blade was like a dart and my arm was like a dart board."
One nurse reported being stabbed in the buttocks by bloody surgical scissors. Patients who "jerked, were combative, tried to bite, scratched or spit on HCWs resulted in several HCW exposures," according to the researchers. A few of the employees who were exposed as a result of patient behavior still blamed themselves for the incident.
Exposed HCWs frequently reported unsafe practices such as recapping, uncapping, and unscrewing needles from vacutainer holders, and using a Kelly clamp to unscrew vacutainer needles — practices in conflict with hospital policy. Splashes and sprays to the eyes frequently occurred when HCWs did not wear a face shield or goggles.
Sixty percent of HCWs went to the clinic immediately after their exposures, and 29% visited the clinic within the recommended two hours. Almost 11% waited more than a day, mostly because they said they didn’t have time to go.
"We were especially interested in determining how long health care workers had to wait before they received treatment," Gershon says. She found that 64% were seen within 15 minutes after they arrived at the clinic. Only 4% had to wait more than two hours. Some health care workers reported problems when they called the exposure hotline after hours, because the operator did not know whom to contact.
Postexposure prophylaxis (PEP) was recommended for 27% of respondents, though several had misconceptions about their risk and need for PEP. For example, one HCW assumed she did not need PEP because the source of the exposure had been a patient who had tested negative for HIV three months earlier. Some of the subjects whose exposures warranted post exposure prophylaxis received no follow-up medications.
Some said making the decision of whether to receive PEP was difficult and that the educational material from the clinic was "overwhelming." Some HCWs refused to start PEP because they feared the side effects. Subjects who received PEP reported numerous PEP drug-related symptoms, including nausea, stomach ache, fatigue, head ache, and diarrhea.
Treatment and follow-up care
For the most part, respondents were satisfied with follow-up care, but virtually all would have welcomed reminders of when to return for PEP vaccines and follow-up testing and being informed more quickly about test results of the source of the exposure.
Some respondents said follow-up care could be improved by incorporating postexposure testing at 12, 18, and even 24 months after the incident. Respondents also indicated they would welcome an opportunity to talk to managers and co-workers about exposure incidents so similar events could be avoided. Others said they wanted more and better training regarding the prevention of bloodborne pathogen exposures. In general, exposed HCWs said they wanted their co-workers to be more careful and alert in situations when the risk of an exposure is high and to adhere closely to hospital safety policies and procedures.
More than half of the study subjects reported anxiety after their exposures, 18% reported insomnia, 13% said they became depressed, 10% reported loss of appetite, and 10% reported frequent crying.
Some employees said that they felt angry and upset as long as a year after the incident, even when they learned that the source of the exposure tested negative for hepatitis C and HIV, according to Gershon. Some were angry with co-workers for their carelessness. Others started thinking about a career change, while some just resigned themselves to the risks inherent in their profession. One resident wrote that it was unfair to be expected to perform difficult needlesticks without having been adequately trained.
Exposed HCWs reported relationship problems
Effects on family and other relationships were significant in some cases. Some were afraid to tell family members about the exposure because of shame or fearing a lack of support. Most exposed HCWs either abstained from sex or practiced safe sex while they waited for test results. One nurse wrote, "I was afraid to have sex with my spouse. He did not understand. We are separated now." Others reported similar sex-related difficulties with partners.
Based on the study results, Gershon and her colleagues offered several recommendations for the management of exposed HCWs. They include the following:
• Department managers should be required to respond to and review each exposure incident. At least aggregate exposure data for an institution should be carefully reviewed by the appropriate committee.
• Employee health departments should survey all exposed HCWs after their treatment protocols have ended.
• Employee health program managers should periodically review the postexposure program and PEP protocols to adjust for any public health recommendations and recommendations from exposed staff members.
• A simple PEP program description and PEP instructions should be given to all new employees at orientation.
• Counseling should be made available to both the HCWs and to their spouses or partners and families.
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